Alcohol Dependence: Provisional Description of a Clinical Syndrome.

W Edwards and Gross pulished this article in 1976, estab­ lishing diagnostic criteria for alcoholism was becoming in­ creasingly important. Much time had passed since Jellinek, in his book The Disease Concept of Alcoholism (1960), energized an interest in an area of nosology (the classification of diseases) that had been ignored for centuries. Because of Jellinek’s work, it was no longer necessary to consider alcoholism (also known as i n t e mp e r a n c e , d ip s o m a n i a, F o l i e Alcoolique ) as the simpl e conse­ quence of a lack of willpo wer or moral fiber and as a condition that was diagnosed solely by the docu­ m e n t a t i o n o f s e v e r e w i t h d r a w a l symptoms. Attention was now called to a complex interaction between a variety of areas of life impairment, and there was a concomitant recogni­ tion by clinicians and researchers that there were likely to be important sub­ groups of alcoholics with different prognoses and potential treatments. T h i s r e n a i s s a n c e i n s p i r e d b y Jellinek prompted input into diag­ nostic criteria from behaviorists, sci­ entists interested in learning theory, biologists, and recovering alcoholics. For example, the Washington Uni­ versity criteria, the National Council o n A l c o h o l i s m c r i t e r i a , a n d t h e Research Diagnostic Criteria were all attem pts to define alcoholis m more fully. It is in this context that Edwards and Gross published their seminal article, which offered a pro­ visional description of the clinical syndrome of alcohol dependence. Edwards and Gross’ observations, which pulled together behavioral, learning, and biological theories, were strongly influenced by their in­ volvement in a 1975 meeting of a di­ agnostic criteria steering group for the World Health Organization. In their article, Edwards and Gross list­ ed seven domains of alcohol­related life experiences that were believed to compose a syndrome or at least what they referred to as a “concurrence of phenomena.” They pro posed th at most al coh ol­dep endent men a nd women will demonstrate some com­ bination of these symptoms, imply­ ing that the greater the number of p r o b l e m s , t h e m o r e i n t e n s e t h e severity of the alcoholism. Five of the seven domains were rela­ tively straightforward and fairly easy to implement in clinical practice and research paradigms. These were an increasing salience of alcohol to the lifestyle; evidence of tolerance; the repeated demonstration of withdrawal symptoms (described by Edwards and Gross in impressive detail); the use of alcohol to relieve or avoid withdrawal symptoms; and evidence of a subjective awareness of a compulsion to drink, a concept they described as being akin to a loss of control of alcohol use or perhaps a decis ion to not exerc i se control. The two oth er domains were a bit more difficult to define in objective terms. These were a narrowing of the drinking repertoire (indicating an increasing level of rigidness in the pattern of alcohol use) and a rapid reinstatement of dependence following periods of abstinence.

W hen Edwards and Gross pulished this article in 1976, estab lishing diagnostic criteria for alcoholism was becoming in creasingly important. Much time had passed since Jellinek, in his book The Disease Concept of Alcoholism (1960), energized an interest in an area of nosology (the classification of diseases) that had been ignored for centuries. Because of Jellinek's work, it was no longer necessary to consider alcoholism (also known as i n t e mp e r a n c e , d ip s o m a n i a, F o l i e Alcoolique ) as the simpl e conse quence of a lack of willpo wer or moral fiber and as a condition that was diagnosed solely by the docu m e n t a t i o n o f s e v e r e w i t h d r a w a l symptoms. Attention was now called to a complex interaction between a variety of areas of life impairment, and there was a concomitant recogni tion by clinicians and researchers that there were likely to be important sub groups of alcoholics with different prognoses and potential treatments.
T h i s r e n a i s s a n c e i n s p i r e d b y Jellinek prompted input into diag nostic criteria from behaviorists, sci entists interested in learning theory, biologists, and recovering alcoholics. For example, the Washington Uni versity criteria, the National Council o n A l c o h o l i s m c r i t e r i a , a n d t h e Research Diagnostic Criteria were all attem pts to define alcoholis m more fully. It is in this context that Edwards and Gross published their seminal article, which offered a pro visional description of the clinical syndrome of alcohol dependence.
Edwards and Gross' observations, which pulled together behavioral, learning, and biological theories, were strongly influenced by their in volvement in a 1975 meeting of a di agnostic criteria steering group for the World Health Organization. In their article, Edwards and Gross list ed seven domains of alcoholrelated life experiences that were believed to compose a syndrome or at least what they referred to as a "concurrence of phenomena." They pro posed th at most al coh oldep endent men a nd women will demonstrate some com bination of these symptoms, imply ing that the greater the number of p r o b l e m s , t h e m o r e i n t e n s e t h e severity of the alcoholism. Five of the seven domains were rela tively straightforward and fairly easy to implement in clinical practice and research paradigms. These were an increasing salience of alcohol to the lifestyle; evidence of tolerance; the repeated demonstration of withdrawal symptoms (described by Edwards and Gross in impressive detail); the use of alcohol to relieve or avoid withdrawal symptoms; and evidence of a subjective awareness of a compulsion to drink, a concept they described as being akin to a loss of control of alcohol use or perhaps a decis ion to not exerc i se control. The two oth er domains were a bit more difficult to define in objective terms. These were a narrowing of the drinking repertoire (indicating an increasing level of rigidness in the pattern of alcohol use) and a rapid reinstatement of dependence following periods of abstinence.
Even more impressive than Edwards and Gross' diagnostic algorithm itself (which the authors labeled as provisional and open to modification) is the clinical wisdom set forth in their de scription of this concept. For example, Edwards and Gross warned that the emphasis should be on the increasing priority drinkers give to maintaining their alcohol consumption (not only its overall intensity) to avoid confusing alcohol problems that are related to high levels of impulsivity with problems that are most relevant to a diagnosis of alcohol dependence. The authors also observed that the subjective aspects of a compulsion to drink are highly variable and intermittent, implying that alcoholdependent men and women are likely to experience limited periods of control over their alcohol intake. Although many alcoholics find absti nence "surprisingly easy to maintain" in specific situations such as on a treatment ward when normal drinking cues are removed, they will begin to drink again later, relapsing into their previous stage of dependence. Rapid reinstatement of alcohol problems after a period of abstinence is accompanied by the caveat that those with very high levels of dependence are likely to never regain control of their drinking. Edwards and Gross were careful to avoid sug gesting that there is a rigid progression of alcohol problems lead i ng to de p e n d ence t h a t appl i e s to e v er y o n e. I n st ead, they suggested that the degrees of the dependence syndrome, as with most syndromes, are "shaped and colored by personality and envi ronment." Elements of the dependence syndrome as defined by Edwards and Gross found their way into the official diagnostic systems w i t h t h e 1 9 7 7 p u b

l i c a t i o n o f t h e n i n t h v e r s i o n o f t h e International Classification of Diseases (ICD-9). The 1980 American Psychiatric Association's Diagnostic and Statistical
Manual of Mental Disorders, Third Edition (DSM-III), began to move toward Edwards and Gross' concept by recognizing at least two types of alcoholism, abuse and dependence, and demonstrating that people with alcohol problems did not neces sarily have to show a tolerance to alcohol or experience with drawal symptoms to receive a diagnosis of alcoholism.
The natural evolution of these diagnostic systems culminated in the third revised version of the Diagnostic and Statistical Manual in 1987 (DSM-III-R), whose description of alcoholism was based primarily on Edwards and Gross' definitions of de pendence. The most recent versions of both manuals, published as ICD-10 (1992) and DSM-IV (1994), are now in close agree ment on this definition of dependence (although they diverge rather widely on the criteria for the less intense alcoholrelated phenomenon, abuse or harmful use).
Although animal models and some clinical data do exist that offer general support for the existence of the dependence syn drome as defined by Edwards and Gross, there is no definitive research that supports such a complex concept. However, both DSM-IV and ICD-10 pay homage to the clinical usefulness of the Edwards and Gross approach. For example, as part of the process of preparing DSM-IV for publication, a field trial was performed using more than 1,000 subjects. It compared the clini cal coverage (i.e., the proportion of impaired subjects who re ceived a diagnosis) and the clinical correlates of the dependence syndrome with alternative versions of a diagnosis of alcoholism; the Edwards and Gross approach for defining dependence was at least as good as any other diagnostic system for defining alco holism that was evaluated. This description of alcoholism pro p o s e d b y E d w a r d s a n d G r o s s a n d u s e d i n D S M -I V h a s additional benefits. The dependence syndrome could be applied to drugs other than alcohol, components of the dependence ap proach could be tested in both animals and humans, and there are some indications that severity of dependence might be related to the number of problems identified.
In considering Edwards and Gross' article from the perspec tive of the two decades that have passed since its publication, it is clear that it continues to occupy a pivotal position in the alco hol field. The authors have not produced an inviolable dictum but offer an exceptionally useful provisional description of a clinical syndrome. Edwards and Gross point out that additional research is required on the optimal definition of each of the con cepts they outline as well as on the appropriate cutoff point for demonstrating the existence of pathology. Research also is nec essary to explore alternative definitions of subgroups based on age, gender, and cultural background, and work is underway to attempt to understand more about the social, biological, and learning model components of the dependence syndrome.
In summary, this article deserves this accolade, which others in the alcohol field can only hope might someday be applied to their work: The field has been significantly enriched by its publication. ■